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December 2010

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From:
Don Ridgway <[log in to unmask]>
Reply To:
UVM Flownet <[log in to unmask]>
Date:
Mon, 6 Dec 2010 21:21:14 -0800
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Bill, my problem with pouncing on an isolated gastroc clot with anticoagulation is that the treatment might turn out to be more harmful than the condition. I think your suggestion to the referring doc, "We can rescan in a few days," or something like that, makes the best sense. 

I've seen gastroc clots propagate, but not so very often. And I've seen heparin cause trouble when administered for isolated calf clot; I recall one patient who bled into the knee joint of the other leg, and was still limping a year later. 

Ben Franklin? 

Don Ridgway





-----Original Message-----
From: UVM Flownet on behalf of Bill Johnson
Sent: Mon 12/6/2010 3:17 PM
To: [log in to unmask]
Subject: Re: Superficial vs. deep
 
Bill Johnson, Port Townsend, WA.

Don Ridgway to UVMFLOWNET

Don, I always love discussing things with you, mainly because you always
question authority.  I believe to this day that was Ben Franklin's Major
issue with the world. I am still in awe at his ability to understand things
that seem so simple today but were so complex then.

I fear the issue here is not about what constitutes a deep vein.  No, it is
more about what we tell the referring source that will determine how they
treat our patient.  Deep vs. superficial?  The real issue is not anatomical,
it is about best care.  I know you know that and I respect that you teach
that, but there is always so much we do not know it makes me shiver.  I
accept your definition of "muscular" veins, since it makes greater sense
than many definitions.  I have been faced many times with the question
"Gastroc veins, is that a deep vein thrombosis???"  "Muscular veins" might
mitigate that, but if the issue is providing appropriate care to the
patient, I would always say, yes, this is Deep Vein Thrombosis, they are
certainly not superficial, and I have seen them many times extend into full,
dangerous, deep vein thrombosis.

*Gastrocnemius veins accompany sural arteries, so are those deep veins? I
wouldn't label them "deep veins,", though they are deeper than superficial
veins; I like the term "muscular veins." They also fall into the category of
"if they propagate..."*

These are subtle distinctions that not all referring docs are interested in.
 How to treat?  Fortunately or not, we do not have to answer this question,
but unfortunately, we are often asked.

I think it is important that we are asked , as much as I think it important how
we respond to that question.


On Mon, Dec 6, 2010 at 1:06 PM, Don Ridgway <[log in to unmask]> wrote:

> Gastrocnemius veins accompany sural arteries, so are those deep veins? I
> wouldn't label them "deep veins,", though they are deeper than superficial
> veins; I like the term "muscular veins." They also fall into the category of
> "if they propagate..."
>
> These are subtle distinctions that not all referring docs are interested
> in. How to treat?
>
> Don Ridgway
>
>
>
>
> -----Original Message-----
> From: UVM Flownet on behalf of Bill Johnson
> Sent: Mon 12/6/2010 12:41 PM
> To: [log in to unmask]
> Subject: Superficial vs. deep
>
>  Bill Johnson, Port Townsend, WA
>
>
>
> Carol wrote;
>
> "*Bill et all,* (Not the Bill you asked, I am another Bill)
>
> *I have a question.  I've had a couple pts recently with superficial
> thrombosis extending into a perforator (beneath the fascia) but not into a
> tibial vein.  I say this is DVT, my medical director does not think so.
>  Who
> is right?  **Thank you *
>
> *Carol Wise, RN, RVT, RDCS Technical Director, Vascular Laboratory"*
>
>
>
> I think perforators fall into one of those "in-between" categories.
>  Neither
> fish nor fowl as it were.  The fascia is usually the boundary between the
> "deep" and the "superficial" ("superficial femoral vein" notwithstanding,
> and hopefully not standing anymore.)  I think the accepted definition of a
> deep vein is that it is adjacent to a deep artery.  I believe your medical
> director is correct.  I also believe that a patient with thrombus in a
> perforator should have serial exams to assure that this does not propagate
> into the deep system which should significantly affect treatment decisions.
>
>
>
>
> I do not think it unlikely that superficial thrombosis cannot be a source
> for embolus, but the issue is the size of the vein and therefore the size
> of
> the potential embolus.  Emboli occur more frequently than we would like to
> know.  I have worked with surgeons that would readily ligate the great
> saphenous vein if thrombus was visualized near the sapheno-femoral
> junction.
> I never thought that was over-reacting.
>
> * *
>
> *http://medical-dictionary.thefreedictionary.com/deep+vein*
> *"deep vein,  one of the many systemic veins that accompany the arteries,
> usually enclosed in a sheath that wraps both the vein and the associated
> artery."  *
> **
> *
>
> There are many other references in the same vein.  ;-)  *Not sure if this
> includes perforators although I have often seen small arteries associated
> with them.  And thrombus within the perforators is not  uncommon.
>
> Not trying to split hairs here, the issue should be patient care.  Your
> concern is obviously based on that.
>
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>
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